Willowbrook Health History Form

Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.

Have you ever been hospitalized or had a major operation?

Yes No

If yes, please explain:

Have you ever had a serious head or neck injury?

Yes No

If yes, please explain:

Are you taking any medications, pills, or drugs?

Yes No

If yes, please explain:

Women: Are you

Pregnant/trying to get pregnant?

Yes No

Taking oral contraceptives?

Yes No

Nursing?

Yes No

Are you allergic to any of the following’?

Aspirin
Penicillin
Codeine
Acrylic
Metal
Latex
Local Anesthetics
Other

If yes, please explain:

Do you have, or have you had, any of the following’?

AIDS/HIV Positive

Yes No

Cortisone Medicine

Yes No

Hemophilia

Yes No

Renat Dialysis

Yes No

Alzheimer's Disease

Yes No

Diabetes

Yes No

Hepatitis A

Yes No

Rheumatic Fever

Yes No

Anaphylaxis

Yes No

Drug Addiction

Yes No

Hepatitis B or C

Yes No

Rheumatism

Yes No

Anemia

Yes No

Easily Winded

Yes No

Herpes

Yes No

Scarlet Fever

Yes No

Angina

Yes No

Emphysema

Yes No

High Blood Pressure

Yes No

Shingles

Yes No

Arthritis/Gout

Yes No

Epilepsy or Seizures

Yes No

Hives or Rash

Yes No

Sickle Cell Disease

Yes No

Artificial Heart Valve

Yes No

Excessive Bleeding

Yes No

Hypoglycemia

Yes No

Sinus Trouble

Yes No

Artificial Joint

Yes No

Excessive Thirst

Yes No

Irregular Heartbeat

Yes No

Spina Bifida

Yes No

Asthma

Yes No

Fainting Spells/Dizziness

Yes No

Kidney Problems

Yes No

Stomach/Intestinal Disease

Yes No

Blood Disease

Yes No

Frequent Cough

Yes No

Leukemia

Yes No

Stroke

Yes No

Blood Transfusion

Yes No

Frequent Diarrhea

Yes No

Liver Disease

Yes No

Swelling of Limbs

Yes No

Breathing Problem

Yes No

FrequentHeadaches

Yes No

Low Blood Pressure

Yes No

Thyroid Disease

Yes No

Bruise Easily

Yes No

Genital Herpes

Yes No

Lung Disease

Yes No

Tonsillitis

Yes No

Cancer

Yes No

Glaucoma

Yes No

Mitral Valve Prolapse

Yes No

Tuberculosis

Yes No

Chemotherapy

Yes No

Hay Fever

Yes No

Pain in Jaw Joints

Yes No

Tumors or Growths

Yes No

Chest Pains

Yes No

Heart Attack/Failure

Yes No

Parathyroid Disease

Yes No

Ulcers

Yes No

Cold Sores/Fever Blisters

Yes No

Heart Murmur

Yes No

Psychiatric Care

Yes No

Venereal Disease

Yes No

Congenital Heart Disorder

Yes No

Heart Pace Maker

Yes No

Radiation Treatments

Yes No

Yellow Jaundice

Yes No

Convulsions

Yes No

Heart Trouble/Disease

Yes No

Recent Weight Loss

Yes No

Have you ever had any serious iliness not listed above?

Yes No

If yes, please explain:

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.

SIGNATURE OF PATIENT, PARENT, or GUARDIAN

Date:

HEALTH HISTORY